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Brand Kanters ART, Roozendaal NC, Parr NMJ, Pasterkamp G, Urbanus RT, Korporaal SJA, de Borst GJ. Perioperative platelet reactivity over time in patients undergoing vascular surgery: An observational pilot study. PLoS One 2024; 19:e0304800. [PMID: 38924073 PMCID: PMC11207130 DOI: 10.1371/journal.pone.0304800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Despite Antiplatelet therapy (APT), cardiovascular patients undergoing revascularisation remain at high risk for thrombotic events. Individual response to APT varies substantially, resulting in insufficient protection from thrombotic events due to high on-treatment platelet reactivity (HTPR) in ≤40% of patients. Individual variation in platelet response impairs APT guidance on a single patient level. Unfortunately, little is known about individual platelet response to APT over time, timing for accurate residual platelet reactivity measurement, or the optimal test to monitor residual platelet reactivity. AIMS To investigate residual platelet reactivity variability over time in individual patients undergoing carotid endarterectomy (CEA) treated with clopidogrel. METHODS Platelet reactivity was determined in patients undergoing CEA in a prospective, single-centre, observational study using the VerifyNow (change in turbidity from ADP-induced binding to fibrinogen-coated beads), the VASP assay (quantification of phosphorylation of vasodilator-stimulated phosphoprotein), and a flow-cytometry-based assay (PACT) at four perioperative time points. Genotyping identified slow (CYP2C19*2 and CYP2C19*3) and fast (CYP2C19*17) metabolisers. RESULTS Between December 2017 and November 2019, 50 patients undergoing CEA were included. Platelet reactivity measured with the VerifyNow (p = < .001) and VASP (p = .029) changed over time, while the PACT did not. The VerifyNow identified patients changing HTRP status after surgery. The VASP identified patients changing HTPR status after eight weeks (p = .018). CYP2C19 genotyping identified 13 slow metabolisers. CONCLUSION In patients undergoing CEA, perioperative platelet reactivity measurements fluctuate over time with little agreement between platelet reactivity assays. Consequently, HTPR status of individual patients measured with the VerifyNow and VASP assay changed over time. Therefore, generally used perioperative platelet reactivity measurements seem unreliable for adjusting perioperative APT strategy.
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Affiliation(s)
- A. R. T. Brand Kanters
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - N. C. Roozendaal
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - N. M. J. Parr
- Clinical Diagnostics Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - G. Pasterkamp
- Clinical Diagnostics Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R. T. Urbanus
- Clinical Diagnostics Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - S. J. A. Korporaal
- Clinical Diagnostics Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Pereira-Macedo J, Duarte-Gamas L, Pereira-Neves A, de Andrade JJP, Rocha-Neves J. Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:71-78. [PMID: 37696419 DOI: 10.1016/j.neucie.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/28/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. MATERIAL AND METHODS From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. RESULTS Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). CONCLUSIONS In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.
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Affiliation(s)
- Juliana Pereira-Macedo
- Department of Surgery, Centro Hospitalar do Médio-Ave, Vila Nova de Famalicão, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - José José Paulo de Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
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Han T, Tang H, Lin C, Zhu J, Shen Y, Yan D, Zhao Z, Lin J, Gao B, Si Y, Wei X, Tang X, Guo D, Fu W. One month follow-up of carotid endarterectomy with in-hospital preoperative aspirin monotherapy and postoperative dual antiplatelet therapy in asymptomatic and symptomatic patients: A multi-center study. Heliyon 2024; 10:e24755. [PMID: 38322935 PMCID: PMC10844113 DOI: 10.1016/j.heliyon.2024.e24755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/15/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
Background There is currently no consensus regarding the optimal perioperative antiplatelet strategy for carotid artery surgery. This multicentre study aimed to analyse the association between preoperative aspirin monotherapy following postoperative dual antiplatelet therapy (DAPT) and the risk for stroke and death after carotid endarterectomy (CEA). Methods This cohort study included 821 patients with carotid artery stenosis who underwent CEA. Primary outcomes included any stroke or death up to the one-month postoperative follow-up. Multilevel multivariate regression analyses and descriptive statistics were performed. Results Patients were predominantly male (53 %), with a mean age of 66.2 years. The primary outcome occurred in 1.6 % of patients. Univariate and multivariate analyses revealed that patients with chronic obstructive pulmonary disease (COPD) exhibited a high risk for stroke or death (P = 0.011). The occurrence of any local complications in the neck was accompanied by an increase in diastolic blood pressure (DBP) (P = 0.007). Patients with a high systolic blood pressure (SBP) (P = 0.002) experienced a longer operative duration. The length of hospital stay was longer in the patients with COPD (P = 0.020), minor stroke (P = 0.011), and major stroke (P = 0.001). A positive linear correlation was found between SBP and operative duration in the overall population (β 0.4 [95 % confidence interval (CI) 0.1-0.7]; P = 0.002). The resultant curve for DBP and any local complications in the neck exhibited a two-stage change and one breakpoint in the entire population (k = 68 mmHg, <68; odds ratio [OR] 0.9 [95 % CI 0.7-1.1], P = 0.461; ≥68: OR 1.1 [95 % CI 1.0-1.1], P = 0.003). Conclusions Preoperative aspirin monotherapy and postoperative DAPT were safe and effective antiplatelet treatments for patients who underwent CEA.
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Affiliation(s)
- Tonglei Han
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Hanfei Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Changpo Lin
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Jiaqi Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yang Shen
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Dong Yan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Jiang Lin
- Department of Radiology, Zhongshan Hospital, Fudan University and Shanghai Institute of Medical Imaging, Shanghai, 200030, China
| | - Bin Gao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Xiaolong Wei
- Department of Vascular Surgery, Changhai Hospital, The PLA Naval Medical University, Shanghai, 200433, China
| | - Xiao Tang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
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Fragão-Marques M, Rocha-Neves J, Andrade JP. Response to the letter "Mean platelet volume may not predict restenosis after carotid endarterectomy" from Beyan C. and Beyan E. Ann Vasc Surg 2022; 83:e6-e7. [PMID: 35337928 DOI: 10.1016/j.avsg.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Mariana Fragão-Marques
- - Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; - Department of Clinical Pathology, Centro Hospitalar Universitário de São João, Porto, Portugal; - Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - João Rocha-Neves
- - Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; - Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - José P Andrade
- - Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; - Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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Flow-cytometry based platelet reactivity testing to predict the occurrence of peroperative solid microemboli during carotid endarterectomy. Eur J Vasc Endovasc Surg 2022; 63:800-806. [DOI: 10.1016/j.ejvs.2022.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 01/15/2022] [Accepted: 03/05/2022] [Indexed: 11/20/2022]
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Ku JC, Taslimi S, Zuccato J, Pasarikovski CR, Nasr N, Chechik O, Chisci E, Bissacco D, Larrue V, Rabinovich Y, Michelagnoli S, Settembrini PG, Priola SM, Cusimano MD, Yang VXD, Macdonald RL. Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:546-555. [PMID: 35241374 DOI: 10.1016/j.ejvs.2021.12.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 12/01/2021] [Accepted: 12/28/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents. DATA SOURCES The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion. REVIEW METHODS The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I2. RESULTS In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature. CONCLUSION This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.
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Affiliation(s)
- Jerry C Ku
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Shervin Taslimi
- Division of Neurosurgery, Department of Surgery, Kingston General Hospital, Toronto, ON, Canada.
| | - Jeffrey Zuccato
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | | | - Ofir Chechik
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Daniele Bissacco
- School of Vascular Surgery, Università degli Studi di Milano, Milan, Italy
| | | | - Yefim Rabinovich
- Sackler Faculty of Medicine, Tel-Aviv Medical Centre, Tel Aviv University, Israel
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | | | - Stefano M Priola
- Division of Neurosurgery, Health Sciences North, Sudbury, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Victor X D Yang
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, Sunnybrook Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, Fresno Campus, Fresno, CA, USA
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Schultz-Lebahn A, Nissen PH, Pedersen TF, Tang M, Hvas AM. Platelet function assessed by ROTEM ® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:18-27. [PMID: 34890293 DOI: 10.1080/00365513.2021.2012820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.
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Affiliation(s)
- Anna Schultz-Lebahn
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Fogh Pedersen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Rocha-Neves J, Pereira-Macedo J, Ferreira A, Dias-Neto M, Andrade JP, Mansilha AA. Impact of intraoperative neurologic deficits in carotid endarterectomy under regional anesthesia. SCAND CARDIOVASC J 2021; 55:180-186. [PMID: 33487041 DOI: 10.1080/14017431.2021.1874509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Patients undergoing carotid endarterectomy (CEA) may experiment neurologic deficits during the carotid cross-clamping due to secondary cerebral hypoperfusion. An associated risk of postoperative stroke incidence is also well established. This work aimed to assess the postoperative adverse events related to neurologic deficits in the awake test after clamping and to determine its predictive factors. Methods. From January 2012 to January 2018, 79 patients from a referral hospital that underwent CEA with regional anesthesia for carotid stenosis and manifested neurologic deficits were gathered. Consecutively selected controls (n = 85) were submitted to the same procedure without developing neurological changes. Postoperative complications such as stroke, myocardial infarction, all-cause death, and Clavien-Dindo classification were assessed 30 days after the procedure. Univariate and binary logistic regressions were performed for data assessment. Results. Patients with clamping associated neurologic deficits were significantly more obese than the control group (aOR = 9.30; 95% CI: 2.57-33.69; p = .01). Lower degree of ipsilateral stenosis and higher degree of contralateral stenosis were independently related to clamping intolerance (aOR = 0.70; 95% CI: 0.49-0.99; p = .047 and aOR = 1.30; 95% CI: 1.06-1.50; p = .009, respectively). Neurologic deficits were a main 30-day stroke predictor (aOR = 4.30; 95% CI: 1.10-16.71; p = .035). Conclusions. Neurologic deficits during carotid clamping are a predictor of perioperative stroke. Body mass index > 30 kg/m2, a lower degree of ipsilateral stenosis, and a higher degree of contralateral stenosis are independent predictors of neurologic deficits and, therefore, might play a role in the prevention of procedure-related stroke.
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Affiliation(s)
- João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - André Ferreira
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Department of Ophthalmology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marina Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José P Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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9
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Rocha-Neves JP, Pereira-Macedo J, Moreira AL, Oliveira-Pinto JP, Afonso G, Mourão J, Andrade JP, Vaz RP, Mansilha A. Efficacy of near-infrared spectroscopy cerebral oximetry on detection of critical cerebral perfusion during carotid endarterectomy under regional anesthesia. VASA 2020; 49:367-374. [DOI: 10.1024/0301-1526/a000879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: Patients undergoing carotid endarterectomy (CEA) may suffer from cerebral hypoperfusion during the carotid cross-clamping. Near-infrared spectroscopy cerebral oximetry (NIRS) is a non-invasive method of regional cerebral oxygen saturation measurement reflecting changes in cerebral blood flow during CEA. The main goal of the study was to evaluate the accuracy of the NIRS in detecting cerebral hypoperfusion during CEA under regional anesthesia (RA) and compare it with awake neurological testing. Patients and methods: A prospective observational study of 28 patients that underwent CEA in RA and manifested neurologic deficits, and 28 consecutive controls from a tertiary and referral center, was performed. All patients were monitored with NIRS cerebral oximetry and awake testing as the control technique. Subsequently, operating characteristic curve and Cohen’s kappa coefficient were determined to evaluate the reliability of the monitoring test. Results: NIRS presented a sensitivity of 27.3% and a specificity of 89.3% in comparison to awake testing. Receiver operating characteristic (ROC) curve analysis demonstrated that a decrease of at least 20% in cerebral oxygen saturation is the best threshold to infer cerebral hypoperfusion. However, the respective area under the curve (AUROC) was 0.606 (95% CI: 0.456–0.756, P = 0.178) with a calculated Cohen’s kappa of 0.179, P = 0.093. Regarding 30-days outcomes, only awake testing has shown significant associations with stroke and postoperative complications ( P = 0.043 and P = 0.05), which were higher in patients with post-clamping neurologic deficits. Conclusions: NIRS demonstrated a reduced discriminative capacity for critical cerebral hypoperfusion, and does not seem to add substantial clinical benefits to the awake test.
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Affiliation(s)
- João P. Rocha-Neves
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - André L. Moreira
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Cardiovascular R&D Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - José P. Oliveira-Pinto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Cardiovascular R&D Unit, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Graça Afonso
- Departamento de Anestesiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Joana Mourão
- Departamento de Anestesiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Serviço de Anestesiologia, Centro Hospitalar São João, Porto, Portugal
| | - José P. Andrade
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Ricardo P. Vaz
- Department of Biomedicine, Unity of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Armando Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Mansilha AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular 2020; 28:505-512. [DOI: 10.1177/1708538120922098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.
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Affiliation(s)
- João M Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina F Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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11
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Jiang QL, Wang PJ, Liu HX, Huang LL, Kang XK. Dual versus Single Antiplatelet Therapy in Carotid Artery Endarterectomy: Direct Comparison of Complications Related to Antiplatelet Therapy. World Neurosurg 2020; 135:e598-e609. [PMID: 31870823 DOI: 10.1016/j.wneu.2019.12.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA. METHODS This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results. RESULTS A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P < 0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P < 0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P < 0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563). CONCLUSIONS Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time.
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Affiliation(s)
- Qun-Long Jiang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Pei-Jian Wang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Hui-Xin Liu
- Department of Medical Examination, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Li-Li Huang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China
| | - Xiao-Kui Kang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, R.P. China.
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12
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Vieira-Andrade JD, Rocha-Neves JP, Macedo JP, Dias-Neto MF. Onset of Neurological Deficit During Carotid Clamping With Carotid Endarterectomy Under Regional Anesthesia Is Not a Predictor of Carotid Restenosis. Ann Vasc Surg 2019; 61:193-202. [DOI: 10.1016/j.avsg.2019.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023]
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13
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Zimmermann A, Knappich C, Tsantilas P, Kallmayer M, Schmid S, Breitkreuz T, Storck M, Kuehnl A, Eckstein HH. Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice. J Vasc Surg 2018; 68:1753-1763. [DOI: 10.1016/j.jvs.2018.01.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/27/2018] [Indexed: 11/17/2022]
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14
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Saedon M, Saratzis A, Lee RWS, Hutchinson CE, Imray CHE, Singer DRJ. Registry report on prediction by Pocock cardiovascular score of cerebral microemboli acutely following carotid endarterectomy. Stroke Vasc Neurol 2018; 3:147-152. [PMID: 30294470 PMCID: PMC6169612 DOI: 10.1136/svn-2017-000116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/10/2017] [Accepted: 11/12/2017] [Indexed: 11/26/2022] Open
Abstract
Background Cerebral microemboli may lead to ischaemic neurological complications after carotid endarterectomy (CEA). The association between classical cardiovascular risk factors and acute cerebral microemboli following carotid surgery has not been studied. The aim of this study was to explore whether an established cardiovascular risk score (Pocock score) predicts the presence of cerebral microemboli acutely after CEA. Subjects and methods Pocock scores were assessed for the 670 patients from the Carotid Surgery Registry (age 71±1 (SEM) years, 474 (71%) male, 652 (97%) Caucasian) managed from January 2002 to December 2012 in the Regional Vascular Centre at University Hospitals Coventry and Warwickshire NHS Trust, which serves a population of 950 000. CEA was undertaken in 474 (71%) patients for symptomatic carotid stenosis and in 196 (25%) asymptomatic patients during the same period. 74% of patients were hypertensive, 71% were smokers and 49% had hypercholesterolaemia. Results A high Pocock score (≥2.3%) was significantly associated with evidence of cerebral microemboli acutely following CEA (P=0.039, Mann-Whitney (MW) test). A Pocock score (≥2.3%) did not predict patients who required additional antiplatelet therapy (microemboli signal (MES) rate >50 hour-1: P=0.164, MW test). Receiver operating characteristic analysis also showed that the Pocock score predicts acute postoperative microemboli (area under the curve (AUC) 0.546, 95% CI 0.502 to 0.590, P=0.039) but not a high rate of postoperative microemboli (MES >50 hour−1: AUC 0.546, 95% CI 0.482 to 0.610, P=0.164). A Pocock score ≥2.3% showed a sensitivity of 74% for the presence of acute postoperative cerebral microemboli. A Pocock score ≥2.3% also showed a sensitivity of 77% and a negative predictive value of 90% for patients who developed a high microembolic rate >50 hour−1 after carotid surgery. Conclusion These findings demonstrate that the Pocock score could be used as a clinical tool to identify patients at high risk of developing acute postoperative microemboli.
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Affiliation(s)
- Mahmud Saedon
- Nottingham University Hospitals NHS Trust, Nottingham, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Rachel W S Lee
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | - Donald R J Singer
- Yale School of Medicine, New Haven, Connecticut, USA.,Fellowship of Postgraduate Medicine, London, UK
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15
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Kragsterman B, Nordanstig A, Lindström D, Strömberg S, Thuresson M, Nordanstig J. Editor's Choice – Effect of More Expedited Carotid Intervention on Recurrent Ischaemic Event Rate: A National Audit. Eur J Vasc Endovasc Surg 2018; 56:467-474. [DOI: 10.1016/j.ejvs.2018.06.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/18/2018] [Indexed: 11/27/2022]
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16
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Sucu N, Özeren M, Karaca MK, Bilgiç A, Büyükbaş A. Should We Be Afraid of Antiplatelet Treatment before Carotid Endarterectomy? Ann Thorac Cardiovasc Surg 2018; 24:213-214. [PMID: 29848839 PMCID: PMC6102602 DOI: 10.5761/atcs.lte.18-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nehir Sucu
- Cardiovascular Surgery Department, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Murat Özeren
- Cardiovascular Surgery Department, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Mehmet Kerem Karaca
- Cardiovascular Surgery Department, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Abdulkadir Bilgiç
- Cardiovascular Surgery Department, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Ayşegül Büyükbaş
- Cardiovascular Surgery Department, Faculty of Medicine, Mersin University, Mersin, Turkey
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17
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Illuminati G, Schneider F, Pizzardi G, Masci F, Calio' FG, Ricco JB. Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study. Ann Vasc Surg 2017; 40:39-43. [DOI: 10.1016/j.avsg.2016.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
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18
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Chisci E, Rehring TF, Pigozzi C, Colon S, Borgheresi A, Tramacere L, Ercolini L, Michelagnoli S. Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after carotid endarterectomy. J Vasc Surg 2016; 64:985-989.e2. [PMID: 27266596 DOI: 10.1016/j.jvs.2016.04.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/05/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine predictors of cranial nerve injury (CNI) after carotid endarterectomy (CEA). METHODS Consecutive CEAs performed over a 5-year period were enrolled in this study. Outcomes analyzed included 30-day major adverse event rate (composite of stroke, death, and myocardial infarction), death, stroke, disabling stroke, myocardial infarction, cervical hematoma and CNI rate, reoperation, and hospital readmission at 30 days. RESULTS There were 1258 CEAs were included in the study, 1168 (93%) were performed using an eversion technique. Patients with symptoms comprised 27% of the cohort (n = 340). At 30 days, there were no deaths, 23 major adverse events (1.8%), 11 strokes (0.9%: nine minor, two major), 12 myocardial infarctions (0.9%), 41 cervical hematomas (3.3%), 9 reoperations (0.7%) and 10 hospital readmissions (0.8%). Median duration of stay was 1 day (interquartile range, 1-2 days). CNI rate at discharge was 2.3% (n = 29). Two patients (9%) had more than one cranial nerve affected. The marginal mandibular branch of the facial nerve was most frequently involved (n = 16; 52%), followed by the hypoglossal (n = 9; 29%), the vagus (n = 4; 13%), and the spinal accessory nerve (n = 2; 6%). Horner's syndrome, consistent with an injury to the cervical sympathetic chain, occurred in 13 patients (1%) who had a true cranial nerve affected as well. The vast majority (94%) of these CNIs and all Horner's syndrome neurapraxias were transient; only the two accessory lesions persisted at their follow-up visit (median, 32 months; range, 8-72 months). Significant predictors for CNI included diabetes (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0-6.2; P = .048), cervical hematoma (OR, 41.7; 95% CI, 13.8-125.4; P < .001), and dual antiplatelet therapy (OR, 4.4; 95% CI, 1.7-11.4; P = .002). CONCLUSIONS CNI is predominantly a transient complication, but is associated significantly with dual antiplatelet therapy use and the occurrence of a postoperative cervical hematoma. Scrupulous attention to hemostasis might reduce the incidence of CNI.
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Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy.
| | - Thomas F Rehring
- Vascular and Endovascular Surgery, Colorado Permanente Medical Group, Kaiser Permanente Colorado Region, Denver, Colo
| | - Clara Pigozzi
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Serena Colon
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Alessandra Borgheresi
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Luciana Tramacere
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Leonardo Ercolini
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
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19
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Guo J, Gu Y, Guo L, Yu H, Qi L, Tong Z, Zhang J, Wang Z. Effects of Sarpogrelate Combined with Aspirin in Patients Undergoing Carotid Endarterectomy in China: A Single-Center Retrospective Study. Ann Vasc Surg 2016; 35:183-8. [PMID: 27238992 DOI: 10.1016/j.avsg.2016.01.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 12/17/2015] [Accepted: 01/06/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing carotid artery stenosis who are prescribed aspirin, clopidogrel, or sarpogrelate as treatment options to inhibit platelet aggregation continues to increase. The purpose of this study was to compare the efficacy and safety of clopidogrel combined with aspirin (CA) versus sarpogrelate combined with aspirin (SA) treatment in carotid endarterectomy (CEA) patients. METHODS This retrospective study included 197 CEA patients (mean age 61.4 years, mean follow-up time 42.5 months), who were divided into a CA group (Group A: 65 male and 44 female patients) and an SA group (Group B: 58 male and 30 female patients). Preoperative demographic and clinical characteristics and postoperative results were compared between the 2 groups and statistically analyzed. RESULTS Preoperative demographic and clinical characteristics, transfusions, hospital stay, occurrence of transient ischemic attack, stroke, myocardial infarction, restenosis, general or life-threatening bleeding, and 30-day mortality showed no significant differences between the 2 CEA patient groups. However, the mean operative blood loss (P = 0.023) and the operative time (P = 0.040) were significantly higher in Group A compared with Group B. A highly significant incidence of neck hematoma (P = 0.024) was observed in patients of Group A. CONCLUSIONS In this study on CEA patients, antiplatelet treatment with CA resulted in a significant risk of developing neck hematoma, increased operative blood loss, and operative time compared with SA treatment. Long-term prospective studies with larger study populations are needed to further confirm the utility of SA treatment for CEA patients.
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Affiliation(s)
- Jianming Guo
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China.
| | - Lianrui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Hengxi Yu
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Lixing Qi
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Zhu Tong
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Jian Zhang
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
| | - Zhonghao Wang
- Department of Vascular Surgery, Xuanwu Hospital, Institute of Vascular Surgery, Capital Medical University, Beijing, China
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20
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Jones DW, Goodney PP, Conrad MF, Nolan BW, Rzucidlo EM, Powell RJ, Cronenwett JL, Stone DH. Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy. J Vasc Surg 2016; 63:1262-1270.e3. [PMID: 26947237 DOI: 10.1016/j.jvs.2015.12.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 12/18/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes. METHODS Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003-2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity. RESULTS Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43-0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41-0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44-0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant. CONCLUSIONS Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.
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Affiliation(s)
- Douglas W Jones
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Mark F Conrad
- Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Brian W Nolan
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Eva M Rzucidlo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jack L Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Schaff M, Gachet C, Mangin PH. [Anti-platelets without a bleeding risk: novel targets and strategies]. Biol Aujourdhui 2016; 209:211-28. [PMID: 26820829 DOI: 10.1051/jbio/2015023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Indexed: 01/29/2023]
Abstract
Anti-platelet agents such as aspirin, clopidogrel and antagonists of integrin αIIbβ3 allowed to efficiently reduce morbidity and mortality associated with arterial thrombosis. A major limit of these drugs is that they increase the risk of bleeding. During the last few years, several innovative anti-thrombotic strategies with a potentially low bleeding risk were proposed. These approaches target the collagen receptor glycoprotein (GP) VI, the GPIb/von Willebrand factor axis, the thrombin receptor PAR-1, the activated form of integrin αIIbβ3 or the ADP receptor P2Y1. While an antagonist of PAR-1 was recently marketed, the clinical proofs of the efficiency and safety of the other agents remain to be established. This review evaluates these new anti-platelet approaches toward safer anti-thrombotic therapies.
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Affiliation(s)
- Mathieu Schaff
- Atherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australie
| | - Christian Gachet
- UMR_S949, INSERM, Etablissement Français du Sang (EFS)-Alsace, Université de Strasbourg, Strasbourg, France
| | - Pierre Henri Mangin
- UMR_S949, INSERM, Etablissement Français du Sang (EFS)-Alsace, Université de Strasbourg, Strasbourg, France
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Kakkos SK, Ellul J, Ntouvas I, Papadoulas SI. Dual antiplatelet therapy for acute minor ischemic stroke or transient ischemic attack. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:176. [PMID: 26366393 DOI: 10.3978/j.issn.2305-5839.2015.07.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Stavros K Kakkos
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - John Ellul
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - Ioannis Ntouvas
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
| | - Spyros I Papadoulas
- Departments of Vascular Surgery and Neurology, University Hospital of Patras, Patras, Greece
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23
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Fleissner F, Redwan A, Bisdas T, Boeck AL, Weissenborn K, Haverich A, Teebken OE, Pichlmaier M, Martens A. Intraoperative Changes in Cerebrospinal Fluid Gas Tensions Reflect Paraplegia During Thoracoabdominal Aortic Surgery. Vasc Endovascular Surg 2015; 49:84-92. [DOI: 10.1177/1538574415595210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: In this study, gas tensions in cerebrospinal fluid (CSF) were prospectively evaluated as intraoperative markers for the detection of neurological deficits. Methods: Spinal fluid, serum, and heart lung machine (HLM) perfusate were monitored for gas tensions (po2/pCo2) and related parameters (pH, lactate, and glucose) during thoracoabdominal aortic repair and correlated with perioperative neurological examination and electrophysiological testing. Results: Forty-seven patients were assessed for the study, and 40 consecutive patients were finally included. The patients were divided into 3 groups: group A (23 patients, 57.5%): no clinical or laboratory signs of neurological damage; group B (14 patients, 35%) who developed subclinical deficits; and group C (3 patients, 7.5%) who had paraplegia. Significant intraoperative changes in CSF gas tensions were observed with postoperative paraplegia. Glucose ratio between serum and CSF showed higher variability in group C, confirming a damage of the blood–brain barrier (BBB). Conclusion: Major neurological damage is reflected by early changes in CSF gas tensions and glucose variability, suggesting damage of the BBB in these patients.
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Affiliation(s)
- Felix Fleissner
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ahmed Redwan
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Theodosios Bisdas
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anna-Lena Boeck
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Axel Haverich
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Omke E. Teebken
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Maximilian Pichlmaier
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich
| | - Andreas Martens
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Salem M, Bown M, Sayers R, West K, Moore D, Nicolaides A, Robinson T, Naylor A. Identification of Patients with a Histologically Unstable Carotid Plaque Using Ultrasonic Plaque Image Analysis. Eur J Vasc Endovasc Surg 2014; 48:118-25. [DOI: 10.1016/j.ejvs.2014.05.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/07/2014] [Indexed: 11/30/2022]
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Rossini R, Musumeci G, Visconti LO, Bramucci E, Castiglioni B, De Servi S, Lettieri C, Lettino M, Piccaluga E, Savonitto S, Trabattoni D, Capodanno D, Buffoli F, Parolari A, Dionigi G, Boni L, Biglioli F, Valdatta L, Droghetti A, Bozzani A, Setacci C, Ravelli P, Crescini C, Staurenghi G, Scarone P, Francetti L, D’Angelo F, Gadda F, Comel A, Salvi L, Lorini L, Antonelli M, Bovenzi F, Cremonesi A, Angiolillo DJ, Guagliumi G. Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EUROINTERVENTION 2014; 10:38-46. [DOI: 10.4244/eijv10i1a8] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sharpe R, Sayers R, London N, Bown M, McCarthy M, Nasim A, Davies R, Naylor A. Procedural Risk Following Carotid Endarterectomy in the Hyperacute Period after Onset of Symptoms. Eur J Vasc Endovasc Surg 2013; 46:519-24. [DOI: 10.1016/j.ejvs.2013.08.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/27/2013] [Indexed: 11/16/2022]
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Delay Prior to Expedited Carotid Endarterectomy: A Prospective Audit of Practice. Eur J Vasc Endovasc Surg 2013; 46:404-10. [DOI: 10.1016/j.ejvs.2013.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/23/2013] [Indexed: 01/06/2023]
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Naylor A, Sayers R, McCarthy M, Bown M, Nasim A, Dennis M, London N, Bell P. Closing the Loop: A 21-year Audit of Strategies for Preventing Stroke and Death Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2013; 46:161-70. [DOI: 10.1016/j.ejvs.2013.05.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 05/07/2013] [Indexed: 10/26/2022]
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Blackshear JL, Brott TG. Ascertainment of any and all neurologic and myocardial damage in carotid revascularization: the key to optimization? Expert Rev Cardiovasc Ther 2013; 11:469-84. [PMID: 23570360 DOI: 10.1586/erc.13.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The majority of carotid revascularization procedures performed at present are in asymptomatic patients. Since such procedures convey no immediate benefit, but rather protect from future hazard, optimization of procedural safety is mandatory. The authors focus their discussion on the methodologies that assess periprocedural myocardial damage and brain injury, as used in past clinical trials, from the fields of perioperative medicine and neurovascular imaging, and discuss methodologies to reduce both events in carotid revascularization.
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Affiliation(s)
- Joseph L Blackshear
- Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Changes in middle cerebral artery velocity after carotid endarterectomy do not identify patients at high-risk of suffering intracranial haemorrhage or stroke due to hyperperfusion syndrome. Eur J Vasc Endovasc Surg 2013; 45:562-71. [PMID: 23541499 DOI: 10.1016/j.ejvs.2013.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 02/27/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine if significant increases in middle cerebral artery velocity (MCAV) or pulsatility index (PI) during and immediately after carotid endarterectomy (CEA) were predictive of patients suffering a stroke due to the hyperperfusion syndrome (HS) or intracerebral haemorrhage (ICH). METHODS Transcranial Doppler (TCD) mean/peak MCAV and PI were recorded pre-operatively; pre-clamp; 1-min post-declamping; 10-min post-declamping and 30-min post-operatively. The study was divided into two time periods; Group 1 (1995-2007); where there was no formal guidance for managing post-CEA hypertension (PEH) and Group 2 (2008-2012); where written guidelines for treating PEH were available. RESULTS 11/1024 patients in Group 1 (1.1%) suffered a stroke due to HS/ICH, compared to 0/426 patients (0.0%) in Group 2 (p = 0.02). In Group 1; intra-operative increases >100% in mean/peak MCAV and PI at 1 and 10-min post-clamp release had positive predictive values (PPV) of 1.2%, 6.3% and 20.0% and 2.9%, 8.0% and 16.6% respectively. Post-operatively; a >100% increase in mean and peak MCAV had a PPV of 6.3% and 2.7% respectively. CONCLUSION We were unable to demonstrate that significant increases in MCAV and PI were able to predict patients at increased risk of suffering a post-operative stroke due to HS or ICH. The provision of written guidance for managing PEH in Group 2 patients was associated with virtual abolition of ICH/HS.
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McMahon GS, Jones CI, Hayes PD, Naylor AR, Goodall AH. Transient heparin-induced platelet activation linked to generation of platelet 12-lipoxygenase. Findings from a randomised controlled trial. Thromb Haemost 2013; 109:1099-107. [PMID: 23494053 DOI: 10.1160/th12-11-0793] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/31/2013] [Indexed: 11/05/2022]
Abstract
Previously we demonstrated that heparin administration during carotid endarterectomy (CEA) caused a marked, but transient increase in platelet aggregation to arachidonic acid (AA) and adenosine diphosphate (ADP), despite effective platelet cyclo-oxygenase-1 (COX-1) inhibition with aspirin. Here we investigated the metabolism of AA via platelet 12-lipoxygenase (12-LOX) as a possible mediator of the observed transient aspirin resistance, and compared the effects of unfractionated (UFH) and low-molecular-weight (LMWH) heparin. A total of 43 aspirinated patients undergoing CEA were randomised in the trial to 5,000 IU UFH (n=22) or 2,500 IU LMWH (dalteparin, n=21). Platelet aggregation to AA (4x10⁻³) and ADP (3x10⁻⁶) was determined, and the products of the COX-1 and 12-LOX pathways; thromboxane B₂ (TXB₂) and 12-hydroxyeicosatretraenoic acid (12-HETE) were measured in plasma, and in material released from aggregating platelets.Aggregation to AA increased significantly (~10-fold) following heparinisation (p<0.0001), irrespective of heparin type (p=0.33). Significant, but smaller (~2-fold) increases in aggregation to ADP were also seen, which were significantly lower in the platelets of patients randomised to LMWH (p<0.0001). Plasma levels of TxB2 did not rise following heparinisation (p=0.93), but 12-HETE increased significantly in the patients' plasma, and released from platelets stimulated in vitro withADP, with both heparin types (p<0.0001). The magnitude of aggregation to ADP correlated with 12-HETE generation (p=0.03). Heparin administration during CEA generates AA that is metabolised to 12-HETE via the 12-LOX pathway, possibly explaining the phenomenon of transient heparin-induced platelet activation. LMWH has less effect on aggregation and 12-HETE generation than UFH when the platelets are stimulated with ADP.
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Affiliation(s)
- Greg S McMahon
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, LE3 9QP, UK
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Salem M, Sayers R, Bown M, West K, Moore D, Robinson T, Naylor A. Features of Unstable Carotid Plaque During and After the Hyperacute Period Following TIA/Stroke. Eur J Vasc Endovasc Surg 2013; 45:114-20. [DOI: 10.1016/j.ejvs.2012.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 11/19/2012] [Indexed: 11/26/2022]
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Histologically unstable asymptomatic carotid plaques have altered expression of genes involved in chemokine signalling leading to localised plaque inflammation and rupture. Eur J Vasc Endovasc Surg 2012; 45:121-7. [PMID: 23265682 DOI: 10.1016/j.ejvs.2012.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 11/07/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many studies have evaluated histological and gene expression profiles in TIA/stroke patients after onset of symptoms, but there is limited understanding as to how these plaque related features interact before symptom onset. In particular, no studies have evaluated differential gene expression in histologically unstable (vs stable plaques) in neurologically asymptomatic patients. METHODS Nine asymptomatic patients had their plaques scored blindly by two independent Histopathologists using the AHA plaque scoring system. RNA extracted from the plaques was hybridised onto a whole genome microarray. Analysis was performed using GenomeStudio (v1.0) and the DAVID bioinformatics resource (v6.7). RESULTS Three plaques were histologically unstable (Grade 2/3), while six were stable (Grade 0/1). 346 differentially expressed genes (>1.3 fold, P < 0.05) were identified (293 down-regulated and 53 up-regulated) between stable and unstable plaques. Genes related to chemokine and protein signalling (pro-inflammatory/pro-apoptotic) were identified to have high enrichment scores (>1.3) and were significantly up-regulated in unstable (asymptomatic) plaques. CONCLUSION The findings confirm the intuitively held belief that changes in chemokine and protein signalling may be associated with acute plaque disruption and precede the onset of symptoms. Once validated, these genes could therefore become targets for innovative medical treatments in the future or could help identify asymptomatic patients with histologically unstable plaques that would benefit from surgical intervention.
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Momjian-Mayor I, Burkhard P, Murith N, Mugnai D, Yilmaz H, Narata AP, Lovblad K, Pereira V, Righini M, Bounameaux H, Sztajzel RF. Diagnosis of and treatment for symptomatic carotid stenosis: an updated review. Acta Neurol Scand 2012; 126:293-305. [PMID: 22607370 DOI: 10.1111/j.1600-0404.2012.01672.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
Carotid stenoses of ≥50% account for about 15-20% of strokes. Their degree may be moderate (50-69%) or severe (70-99%). Current diagnostic methods include ultrasound, MR- or CT-angiography. Stenosis severity, irregular plaque surface, and presence of microembolic signals detected by transcranial Doppler predict the early recurrence risk, which may be as high as 20%. Initial therapy comprises antiplatelets and statins. Benefit of revascularization is greater in men, in older patients, and in severe stenosis; patients with moderate stenoses may also profit particularly if the plaque has an irregular aspect. An intervention should be performed within <2 weeks. In large randomized studies comparing endarterectomy and stenting, endovascular therapy was associated with a higher risk of periprocedural stroke, yet in some studies, with a lower risk of myocardial infarction and of cranial neuropathy. These trials support endarterectomy as the first choice treatment. Risk factors for each of the two therapies have been indentified: coronary artery disease, neck radiation, contralateral laryngeal nerve palsy for endarterectomy, and, elderly patients (>70 years), arch vessel tortuosity and plaques with low echogenicity on ultrasound for carotid stenting. Lastly, in direct comparisons, a contralateral occlusion increases the risk of periprocedural complications in both types of treatment.
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Affiliation(s)
- I. Momjian-Mayor
- Neurology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - P. Burkhard
- Neurology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - N. Murith
- Cardio-Vascular Surgery Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - D. Mugnai
- Cardio-Vascular Surgery Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - H. Yilmaz
- Neuroradiology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - A.-P. Narata
- Neuroradiology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - K. Lovblad
- Neuroradiology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - V. Pereira
- Neuroradiology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - M. Righini
- Angiology and Haemostasis Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - H. Bounameaux
- Angiology and Haemostasis Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
| | - R. F. Sztajzel
- Neurology Department, Faculty of Medicine, Geneva University Hospitals; University of Geneva; Geneva; Switzerland
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Management and Outcome of Prosthetic Patch Infection after Carotid Endarterectomy: A Single-centre Series and Systematic Review of the Literature. Eur J Vasc Endovasc Surg 2012; 44:20-6. [DOI: 10.1016/j.ejvs.2012.04.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 04/30/2012] [Indexed: 11/20/2022]
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Chechik O, Goldstein Y, Behrbalk E, Kaufman E, Rabinovich Y. Blood loss and complications following carotid endarterectomy in patients treated with clopidogrel. Vascular 2012; 20:193-7. [DOI: 10.1258/vasc.2011.oa0336] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study assessed the effect of uninterrupted antiplatelet therapy on perioperative blood loss and complications in patients undergoing carotid endarterectomy. The files of 107 consecutive patients (mean age 69.5 ± 9 years; range 47–88; 78 men) who underwent carotid endarterectomy were reviewed. Twenty-six patients had been treated with clopidogrel (16 of whom were on combined clopidogrel and aspirin treatment) and compared with non-clopidogrel patients. Antiplatelet treatment was continued until the day of surgery without interruption. Perioperative blood loss and complications were studied. The mean hemoglobin decrease was 1.64 ± 1.2 mg/dL and was not significantly affected by clopidogrel. Surgical time was significantly longer among patients treated with clopidogrel (205 ± 52 minutes on combined treatment and 201 ± 68 minutes on clopidogrel alone versus 165 ± 33 minutes, P < 0.0001). Postoperative complications were similar for all groups and included five strokes, five neck hematomas, one nerve injury and one wound infection. In conclusion, patients treated with clopidogrel before carotid endarterectomy can be expected to have prolonged surgical time. Large cohorts are required to determine whether these patients have more complications.
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Affiliation(s)
| | | | | | | | - Yefim Rabinovich
- Department of Vascular Surgery, Tel-Aviv Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Sharpe R, Sayers R, McCarthy M, Dennis M, London N, Nasim A, Bown M, Naylor A. The War Against Error: A 15 Year Experience of Completion Angioscopy Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2012; 43:139-45. [DOI: 10.1016/j.ejvs.2011.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/08/2011] [Indexed: 11/16/2022]
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Naylor A. Hearts and Minds. Eur J Vasc Endovasc Surg 2012; 43:1-3. [DOI: 10.1016/j.ejvs.2011.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/22/2011] [Indexed: 11/30/2022]
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Microembolus detection by transcranial Doppler sonography: review of the literature. Stroke Res Treat 2011; 2012:382361. [PMID: 22195291 PMCID: PMC3236352 DOI: 10.1155/2012/382361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 10/17/2011] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler can detect microembolic signals which are characterized by unidirectional high intensity increase, short duration, random occurrence, and a “whistling” sound. Microembolic signals have been detected in a number of clinical settings: carotid artery stenosis, aortic arch plaques, atrial fibrillation, myocardial infarction, prosthetic heart valves, patent foramen ovale, valvular stenosis, during invasive procedures (angiography, percutaneous transluminal angioplasty), surgery (carotid, cardiopulmonary bypass, orthopedic), and in certain systemic diseases. Microembolic signals are frequent in large artery disease, less commonly detected in cardioembolic stroke, and infrequent in lacunar stroke. This article provides an overview about the current state of technical and clinical aspects of microembolus detection.
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Salem M, Butt H, Watts A, Sayers R, Bown M, Naylor A. Spontaneous Cerebral Embolisation in Asymptomatic and Recently Symptomatic Patients with TIA/Minor Stroke. Eur J Vasc Endovasc Surg 2011; 41:720-5. [DOI: 10.1016/j.ejvs.2011.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
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The Role of Cerebral Oximetry in Combination with Awake Testing in Patients Undergoing Carotid Endarterectomy under Local Anaesthesia. Eur J Vasc Endovasc Surg 2011; 41:599-605. [DOI: 10.1016/j.ejvs.2010.12.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 12/17/2010] [Indexed: 11/21/2022]
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Salem M, Sayers R, Bown M, Eveson D, Robinson T, Naylor A. Rapid Access Carotid Endarterectomy can be Performed in the Hyperacute Period without a Significant Increase in Procedural Risks. Eur J Vasc Endovasc Surg 2011; 41:222-8. [DOI: 10.1016/j.ejvs.2010.10.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 10/27/2010] [Indexed: 11/30/2022]
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Imray CH, Yow H, Tiivas C, Higman DJ. Emboli detection in asymptomatic carotid stenosis. Lancet Neurol 2010; 9:948-9; author reply 949. [PMID: 20864044 DOI: 10.1016/s1474-4422(10)70228-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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